Sedative prescribing among older people doubles with move into residential care, finds study

BMJ 2013; 346 doi: (Published 26 February 2013) Cite this as: BMJ 2013;346:f1272
  1. Caroline White
  1. 1London

The proportion of older people who receive mood altering drugs increases sharply when they move into residential care, a rise that is not fully explained by prescribing rates before admission, a study from Northern Ireland has found.

The findings back up those of other studies in the United Kingdom and are likely to fuel concerns that drugs such as sedatives, tranquillisers, and antipsychotics may be being used as a form of “chemical cosh” among older people in residential care.

In the latest study, researchers from Queen’s University in Belfast drew on national prescribing data on the numbers of psychotropic drugs prescribed to all people aged 65 years or over in Northern Ireland between 2008 and 2010 and data on people’s moves into 345 care homes.1

They found that the use of tranquillisers, sedatives, and antipsychotic drugs was, as expected, more common among older people in residential care than it was among those living in their own homes. But use of such drugs also rose sharply within a month of admission to residential care and continued to rise.

The proportion of elderly people to whom antipsychotics and sedatives were dispensed roughly doubled after they entered care, respectively from 8.2% to 18.6% (risk ratio 2.26 (95% confidence interval 1.96 to 2.59)) and from 14.8% to 26.3% (1.78 (1.61 to 1.96)).

Six months after admission more than a third (37%) of all new residents had been prescribed a sedative at least once, while a similar proportion (30%) had been prescribed an antipsychotic. One in four (25%) had been given a tranquilliser. The equivalent figures for elderly people still living in their own homes were 7.3%, 1.1%, and 3.6%, respectively.

Many elderly people had not been prescribed psychotropic drugs before entering residential care. A sixth of care home residents who had not been prescribed an antipsychotic in the six months before their move into residential care were subsequently prescribed this type of drug within six months of admission.

By January 2009 a fifth of care home residents (20.3%) had been dispensed an antipsychotic, compared with one in 100 (1.1%) of those still living in their own homes.

“Despite a range of warnings, recommendations, and guidelines aimed at ensuring more appropriate use of these medications, the prevalence of psychotropic drug use in residential care homes and nursing homes remains high,” the authors wrote.

They pointed out that sedatives were often prescribed for conditions similar to those warranting antipsychotics but that these drugs are contraindicated in older people, while some anti-anxiety drugs, such as long acting benzodiazepines, are also deemed inappropriate in this age group.

Evidence from other studies indicates that even the newer types of antipsychotics used to control the behavioural and psychological symptoms of dementia can speed up cognitive and functional decline in older people.2 3

“It’s recommended that treatment with psychological therapies should be started first for people with dementia, but it may be that these are not available, so drugs may be the only option,” the study’s lead author, Aideen Maguire, told the BMJ.

Greater prescribing of mood altering drugs among elderly people entering residential care was not unexpected, she added, but it was not clear why the rise was so large and sudden.

“People moving into care are likely to be sicker, and the transition can be stressful, so we would expect to see a gradual increase before and on admission but followed by a levelling off,” she explained. “What is unexpected is how sharp and how immediate the rise was.”

Entry into residential care should prompt an independent drug review by a healthcare professional who is not the person’s GP, followed by regular reviews thereafter, she advised.


Cite this as: BMJ 2013;346:f1272